What is the next step in managing an adult female with a history of unintentional corrosive ingestion and severe esophageal strictures, currently undergoing regular endoscopic dilatation for 3 months with a feeding jejunostomy?

From the Guidelines

The next step in managing this patient with severe esophageal strictures from corrosive ingestion would be to consider surgical intervention, specifically esophageal reconstruction, as continued endoscopic dilatation alone is unlikely to provide long-term resolution after 3 months of treatment. The patient has already undergone regular endoscopic dilatation for 3 months with a feeding jejunostomy, and the lack of sufficient improvement suggests that surgical options should be considered. According to the guidelines, endoscopic dilation is the upfront treatment of esophageal strictures, but reconstructive esophageal surgery should be considered after recurrent failure of endoscopic dilation 1.

The preferred surgical approach would be esophageal replacement using either colonic interposition or gastric pull-up, depending on the extent of injury and patient's anatomy. Preoperatively, the patient should undergo comprehensive evaluation including contrast esophagography, CT imaging, and nutritional optimization while maintaining the feeding jejunostomy for enteral nutrition. Postoperatively, the patient will require close monitoring for anastomotic leaks, stricture recurrence, and reflux.

Some key points to consider in the management of this patient include:

• The role of endoscopy in the management of corrosive ingestion, including the use of the Zargar endoscopic classification to predict stricture formation 1
• The importance of considering surgical intervention after recurrent failure of endoscopic dilation, as recommended by the guidelines 1
• The potential risks and complications of endoscopic dilatation, including perforation, pulmonary aspiration, and bleeding, as reported in the literature 1
• The safety and efficacy of endoscopic dilatation in patients with eosinophilic oesophagitis, as demonstrated in recent studies 1

Overall, the decision to proceed with surgical intervention should be based on a comprehensive evaluation of the patient's condition and the potential benefits and risks of the procedure. Surgery is recommended at this stage because corrosive strictures are typically dense and fibrotic, making them resistant to long-term success with dilatation alone. Additionally, there is concern for increased risk of esophageal carcinoma with long-standing corrosive injury, providing further justification for definitive surgical management 1. The feeding jejunostomy should be maintained until adequate oral intake is established following reconstruction.

From the Research

Management of Esophageal Strictures

The patient in question has a history of unintentional corrosive ingestion, resulting in severe esophageal strictures, and is currently undergoing regular endoscopic dilatation for 3 months with a feeding jejunostomy. The next steps in management can be considered based on the available evidence:

• Continuation of Endoscopic Dilatation: This approach is commonly used for managing esophageal strictures, especially in cases where the stricture is not too severe 2. However, the decision to continue dilatation should be based on the patient's response to the treatment and the presence of any complications.
• Oesophageal Resection: This is a more invasive approach, usually considered in cases where the stricture is severe and not responsive to dilatation, or if there are complications such as perforation or malignancy. The evidence does not directly support this approach as the next step without considering the patient's current response to dilatation and the presence of any complications 3, 4.
• Stent Placement: Stent placement can be an alternative to dilatation in some cases, especially if the stricture is not responsive to dilatation or if the patient has significant symptoms. However, the evidence provided does not directly support stent placement as the next step in this specific scenario 5.
• Oesophageal Bypass: This is a more complex surgical procedure, usually considered in cases where other options are not feasible or have failed. The evidence does not support this approach as the immediate next step without considering less invasive options first 5, 3, 4.

Considerations for Feeding Jejunostomy

The patient currently has a feeding jejunostomy, which is used for enteral nutrition. The decision to continue or remove the jejunostomy should be based on the patient's nutritional needs and the ability to tolerate oral feeding. Studies suggest that feeding jejunostomy tubes can be beneficial in certain cases, such as after esophagectomy, to reduce mortality and support nutrition 3, 4. However, the routine use of jejunostomy tubes and the decision to place or remove them should be individualized based on patient factors and the underlying condition being treated.

Patient Assessment and Decision Making

When deciding on the next steps in management, a comprehensive patient history and assessment are crucial 6. This includes evaluating the patient's response to current treatments, nutritional status, and any complications or symptoms. The decision-making process should involve a multidisciplinary approach, considering the patient's overall health, preferences, and the potential benefits and risks of each option.